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STUDENT DETAILS
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Name: Name Here
Course: Bachelor of Counselling
ASSESSMENT DETAILS
Unit/Module: Project 2
Educator: Name Here
Assessment Name:
Literature review
Assessment Number: 1
Term & Year:
Word Count: 2402 (excluding abstract & headings)
DECLARATION
I declare that this assessment is my own work, based on my own personal research/study . I also declare that
this assessment, nor parts of it, has not been previously submitted for any other unit/module or course, and that I
have not copied in part or whole or otherwise plagiarised the work of another student and/or persons. I have read
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I also declare, if this is a practical skills assessment, that a Client/Interviewee Consent Form has been read and
signed by both parties, and where applicable parental consent has been obtained.
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Self-Harm Among Rural Australian Adolescents: A Literature Review
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Australian College of Applied Psychology
Term 3, 2017
2
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Abstract
This review examines the current literature regarding self-harm among rural
Australian adolescents. The objective was to determine the vulnerabilities and impacts of
self-harm among adolescents in rural Australian communities and explore potential treatment
interventions. Twenty-five papers were selected from approximately 438 abstracts. Limited
data were found reflecting self-harm, specifically among adolescents residing in rural
communities, indicating that further research is needed. The literature revealed that the
prevalence of self-harm among adolescents in general ranges from 4-18% and is almost
double that among rural populations. Various risk-factors were identified as well as
significant risk of suicide among self-harmers. Several factors were also identified as barriers
This treatment
portion offor
text
has been removed
from
this preview.
to receiving adequate
self-harming
behaviour
among
rural adolescents. The
The author has not authorised any further reproduction or communication of this material.
literature suggests that Dialectical Behaviour Therapy (DBT) and family therapies, within
school-based initiatives, as potentially effective interventions for this population. The
proposed intervention offers a 16-week DBT program, alongside a psychoeducational
workshop for parents, delivered within a school setting. It also recommends mental health
promotion within rural communities and schools.
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Self-Harm Among Rural Australian Adolescents: A Literature Review
Adolescent self-harm (ASH) is a significant health concern in Australia (Guerreiro et
al., 2013). Prevalence rates range from 4-18% among the general adolescent population with
many of these individuals later attempting suicide (Freeman et al., 2016). This review
portion
of text has
been in
removed
from thiswhere
preview.
explores self-harmThis
among
adolescents
residing
rural Australia,
the prevalence of
The author has not authorised any further reproduction or communication of this material.
self-harm and suicide is almost double than urban Australia (AIHW, 2014). This review
explores the literature regarding ASH in rural communities, including, prevalence, riskfactors, consequences and needs of this group. It further explores evidence-based treatment
interventions that may be effective in supporting youth resorting to self-harm. A
comprehensive approach, incorporating group DBT and family psychoeducation,
implemented within rural schools, is predicted to be a viable intervention for self-harming
among rural Australian adolescents.
Definitions
Self-harm refers to deliberate damage to one’s own body, without intent of dying,
through self-injurious behaviour (De Kloet et al., 2011; Freeman et al., 2016; Guerreiro et al.,
2013; Hawton et al., 2009). Deliberate self-harm behaviours include, self-cutting, jumping off
This portion
of textillicit
has been
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this preview.
heights and ingestion
of prescribed,
or non-ingestible
substances
(Madge et al., 2008, as
The author has not authorised any further reproduction or communication of this material.
cited in, Guerreiro et al., 2013; Healey, 2014). For the purposes of this review, the term selfharm will be used to describe any deliberate harm to self without intent of death.
This review refers to experiences of self-harm in the context of adolescents,
specifically aged 13-18, residing in rural areas of Australia. ‘Rural’ refers to individuals
living in regional and remote geographical locations, both of which can be included in the
loose definition of ‘rural’ (Kõlves et al., 2012). The review explores the literature within this
context.
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Database Search
A literature review was undertaken to examine self-harm among rural Australian adolescents.
Twenty-five papers were selected from approximately 438 abstracts using EBSCO Host,
Google Scholar and internet searches. Articles were chosen on the basis that they were;
reliable research, relevant to the rural Australian context, referred to adolescents and
published in the last decade. Search criteria included: ‘Self-harm in adolescents in rural
Australia’; ‘Rural adolescent mental health’, ‘Self-harm in rural areas Australia AND
adolescents’ and ‘DBT for self-harm’. Self-harm’ was also searched among E-book databases
which yielded two suitable results. This literature was reviewed by the author, resulting in the
selection of those appearing in this paper.
Review of the Literature on Self-Harm
Prevalence
Prevalence rates for self-harm among adolescents vary from 4% within the general
population to 60–80% among hospital inpatients (De Kloet et al., 2011). Numerous studies
report results ranging from 12-18% for adolescents in general (Freeman et al., 2016; Hawton
et al., 2009; Ougrin et al., 2012). These varying results may reflect the samples, measures,
This portion of text has been removed from this preview.
definitions of self-harm, the secretive nature of the behaviour and disparities in the way
The author has not authorised any further reproduction or communication of this material.
hospitals record data (Fox, Hawton & Fox, 2004). Freeman et al., (2016) assert that it is
difficult to obtain accurate prevalence rates for self-harm.
Self-harm data are much more limited for those in rural communities. In rural areas,
the prevalence is documented to be higher than the general population, increasing with
remoteness (NRHA, 2017). The National Rural Health Association (NRHA) undertook
studies, in 2009 and 2017, which showed that in a one-year period there were 191 hospital
admissions in regional areas and 231 in remote areas following self-harm, as compared to
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125 in major cities. This suggests that rates of self-harm are almost twice as likely in rural
adolescent populations as compared to the general population.
Risk-Factors
There are a multitude of risk-factors documented to predispose adolescents to selfharm. Most notably, psychopathology has been found to be highly predictive of self-harm.
Studies suggest that at least 87% of adolescents who self-harm have coinciding diagnoses
including depression, post-traumatic stress and personality disorders (De Kloet et al., 2011;
Freeman et al., 2016; Guerreiro et al., 2013; Hawton et al., 2009; Madge et al., 2011; Ougrin
et al., 2012). Furthermore, previous suicidal behaviour is one of the most significant
predictive factors for self-harm (Shaffer & Pfeffer, 2001, as cited in, Guerreiro et al., 2013).
This suggests that adolescents are resorting to self-harm due to enduring immense
psychological burden.
Specific individual characteristics may be risk factors for self-harm. Such traits
include; poor problem-solving and emotion regulation skills and withdrawing from social
portion
removed
thisThis
preview.
support (Stanford This
et al.,
2009, of
as text
citedhas
in, been
Guerreiro
et al.,from
2013).
suggests that these
The author has not authorised any further reproduction or communication of this material.
adolescents require social support and the development of new coping skills.
Family life is another influencing factor. Difficulties with parental relationships are
common concerns for adolescents (De Kloet et al., 2011; Hawton et al., 2009). Many studies
have linked parental criticism, unresponsiveness, lacking support and rejection with selfharm, which is frequently preceded by parental conflict (Scott, Diamond & Levy, 2016).
Again, this suggests adolescents may be lacking support and developing more supportive
family relationships may be a protective factor for self-harm. Scott et al. (2016) suggested
that family involvement in treatment would support positive outcomes by addressing this
risk-factor.
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In rural areas, specific risk-factors affect young people including, unemployment,
increased availability of lethal means and barriers to accessing mental health services. These
barriers include, lacking anonymity, self-reliance being culturally embedded, and stigma
This portion
text has
been
removed
from
this preview.particularly
associated with mental
illnessof
(Boyd
et al.,
2007).
Personal
vulnerabilities
The author has not authorised any further reproduction or communication of this material.
magnified by living rurally include, loneliness, lack of community understanding and
untreated depression (NRHA, 2009; NRHA, 2017). These issues may increase isolation and
reduce availability of support. It is evident there are a combination of factors that may
predispose adolescents to self-harm including, psychological disorders, personal
characteristics, family difficulties, as well as additional factors affecting rural communities.
Social and Psychological Impacts
There are significant and detrimental consequences for ASH. The most serious
implication highlighted across the literature was the increased risk of suicide, with at least
70% of adolescents who had self-harmed having also attempted suicide (De Kloet et al.,
2011; Freeman et al., 2016; Guerreiro et al., 2013; Hawton et al., 2009; Ougrin et al., 2012).
In fact, Bennardi et al. (2016) highlighted that repeated self-harm is the strongest suicide riskfactor. Considering rural communities, where adolescent suicide occurs almost twice as often
than in urban areas (NRHA, 2017), addressing self-harm may also reduce suicide prevalence.
Needs
Various needs have been identified for rural ASH arising from the risk-factors and
impacts. These include addressing poor emotion regulation skills, difficult family
relationships and barriers to utilising treatment services. Freeman et al. (2016) highlighted
that developing effective coping strategies and emotion-regulation skills is needed for
adolescents. An appropriate intervention should include such skill development.
As family difficulties are a contributing factor of ASH, there is consensus that family
involvement within treatment interventions may be useful (Hawton et al., 2009; Scott et al.,
This portion of text has been removed from this preview.
The author has not authorised any further reproduction or communication of this material.
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2016). Research suggests that adolescents more commonly seek support from family and
friends as opposed to mental health professionals (Hernan et al., 2010; Rughani, Deane &
Wilson, 2011). This preference was also observed by Ougrin (2012), who asserted that wider
systems, such as school and family, play important roles in addressing ASH. The notion that
family and peers are a preferred support system for adolescents and family difficulties can be
This involving
portion ofthem
text has
been removed
from this
preview.
a risk-factor for ASH,
in treatment
interventions
could
enhance benefits.
The author has not authorised any further reproduction or communication of this material.
The barriers affecting treatment utilisation among rural youth such as stigma, poor
mental health literacy (Boyd et al., 2007) and insufficient access to mental health services
(AIHW, 2014; NRHA, 2009) require attention. Findings suggest that increasing mental health
literacy and understanding of the benefits of seeking help may increase the use of services
(Rughani et al., 2011). It would therefore be important to ensure that intervention strategies
seek to mitigate these barriers by de-stigmatising mental health, providing accessible services
and improving mental health literacy.
While these issues require attention, another factor is that limited literature exists
regarding self-harm among rural adolescents and no interventions have been established as
entirely effective for adolescents (Ougrin et al., 2012; Scott et al., 2016). Therefore, more
research is required among this population to find effective treatments.
Review of Interventions
The evidence suggests various interventions that would be potentially effective in
addressing self-harm. Trials of DBT and family therapies are yet to determine results among
adolescent populations, however, have been found effective among adults (Ougrin, 2012).
DBT is the recommended treatment for adults engaging in self-harm and has been widely
used and tested (Andion et al., 2012; Boyce et al., 2003; Freeman et al., 2016; James et al.,
2008; Low et al., 2001). There have been fewer studies however, adapting this treatment for
use with adolescents
al., has
2016;
James
et al., from
2008;this
Ougrin
et al., 2012). Due to
This(Freeman
portion ofettext
been
removed
preview.
The author has not authorised any further reproduction or communication of this material.
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the specific needs of adolescents, DBT programs for young people differ from standard adult
approaches. Despite this, Muehlenkamp (2006) highlights that adapted versions of DBT with
adolescents have been trialled (as cited in, Freeman et al., 2016).
DBT has a variety of components. Interventions may include, individual
psychotherapy and group skills training (Linehan, 1993, as cited in, Freeman et al., 2016).
Core components include teaching emotion regulation, interpersonal skills, distress tolerance
and mindfulness (Rathus and Miller 2002, as cited in Freeman et al., 2016; James et al.,
2008). Adolescent adaptions of DBT, as recommended by Miller, Rathus and Linehan (2007)
have incorporated additional components including; improving parent and adolescent
communication; family skill-building; family therapies; shorter treatment length of 16Thismaterials
portion offor
text
has been
removedfor
from
this preview.
weeks; and reworded
greater
applicability
teenagers
(as cited in, Freeman et
The author has not authorised any further reproduction or communication of this material.
al., 2016). James et al. (2008) found marked improvements on all self-harm measures using
an adapted version of DBT for female adolescents. Standard DBT appears to address the need
for the development of coping skills among adolescents, while the additional components in
adolescent versions attend to familial risk factors associated with self-harm.
While there is growing evidence to support DBT as a viable intervention for ASH,
some challenges need to be addressed (Freeman et al., 2016). These include; the need for
consistency across studies in defining self-harm, treatment length and measures,
incorporation of all DBT treatment components tailored for adolescents and longitudinal
studies to determine efficacy long-term (Freeman et al., 2016). This suggests further clinical
trials should be undertaken using consistent methods to determine efficacy among rural
adolescents.
Families also play a key role in treating ASH. Kerfoot et al. (1996) asserts that selfharm in adolescents is often associated with family dysfunction and therefore DBT
Thisbeportion
of text
has been removed
fromtherapies
this preview.
interventions should
delivered
in conjunction
with family
(as cited in, James et
The author has not authorised any further reproduction or communication of this material.
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al., 2008). There are various avenues for achieving this such as, group psychoeducation for
parents and family therapy to improve relationships (James et al., 2008; Scott et al., 2016).
De Kloet et al. (2011) validates the importance of parental involvement in treatment due to
family difficulties being a risk-factor for self-harm. Parents are increasingly included in
treatments to target family dynamics linked to risk and protection from self-harm and
increasing family cohesion (Diamond et al., 2014, as cited in, Scott et al., 2016). The
evidence suggests that family involvement in the treatment of ASH has the potential to
improve outcomes and addresses this risk-factor for ASH.
In terms of implementation within a rural setting, other factors would need to be taken
into consideration to address barriers to help-seeking. Boyd et al., (2007); Hawton et al.
(2009); Fortune et al. (2008) assert that for adolescents, access to help is primarily schoolbased and Hawton et al. (2009); Hernan et al. (2010) suggest that school-based initiatives
may offer the most potential for this population. Hernan et al. (2010) further suggest that
health promotion strategies
should
promote
school-based
utilising family
This portion
of text
has been
removedinterventions
from this preview.
The author has not authorised any further reproduction or communication of this material.
involvement for adolescents. Therefore, a viable treatment intervention for self-harm,
specifically adapted to adolescents residing in rural communities should incorporate DBT
with family involvement, delivery within a school setting and health promotion initiatives in
order to address the identified needs of this group.
Proposed Intervention
A recommended intervention program that is evidence-based, and addresses the needs
of rural adolescents who self-harm, would be most effective. Growing evidence suggests
DBT is a promising intervention for ASH (Freeman et al., 2016). The proposed intervention
incorporates three elements including, group DBT for adolescents, psycho-education for
parents and implementation within a school setting.
This portion of text has been removed from this preview.
The author has not authorised any further reproduction or communication of this material.
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The DBT program would be adapted for adolescents. In addition to the inclusion of
core components of DBT, the intervention would also include improving communication
between adolescents and their parents, skills training for parents, 16-week treatment length
and age appropriate materials (Miller, Rathus & Linehan, 2007, as cited in, Freeman et al.,
2016). Furthermore, Boyd et al., (2007); Hawton et al. (2009); Hernan et al. (2010); Francis
et al. (2006); Tormoen et al. (2013) suggest the delivery of ASH interventions should be
school-based for enhanced effectiveness. These elements would be implemented to support
the additional needs of adolescents.
Additionally, family involvement is recommended as being predictive of enhanced
success in treatment interventions for ASH (De Kloet et al., 2011; Scott et al., 2016). The
literature suggests the incorporation of psycho-education for parents within interventions (De
portion
text Scott
has been
removed
from this
preview.
Kloet et al., 2011;This
James
et al.,of
2008;
et al.,
2016). Hence,
a parental
psychoeducation
The author has not authorised any further reproduction or communication of this material.
group would be included that would address topics such as; improving parent-adolescent
communication (Miller, Rathus & Linehan, 2007, as cited in, Freeman et al., 2016) and
increasing family cohesion (Scott et al., 2016). Incorporating family and school involvement
within the intervention is likely to support treatment outcomes.
While no specific intervention has proven effectiveness for treating rural ASH, by
incorporating elements the literature suggests as effective for this population, there is
increased potential for positive outcomes.
Conclusion
The aims of this review were to examine the literature regarding ASH within rural
Australia. As this population has not been extensively studied, much of the data refer to
Australian adolescents in general. However, some key considerations were identified for this
population, including prevalence of self-harm being almost double, coupled with various
barriers to treatment utilisation. The identified needs for this group included; development of
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coping skills, family and school involvement within interventions, improving treatment
access, reducing stigma and providing treatment options for rural adolescents. DBT was the
This portion
of text
has
been removed
from trials
this preview.
recommended treatment
amongst
adult
populations
and some
delivered positive
The author has not authorised any further reproduction or communication of this material.
outcomes for adolescents, despite some challenges that need to be mitigated. In terms of
providing DBT treatments for rural ASH, the literature highlighted that interventions should
incorporate family involvement and be delivered within school-based settings to increase
potential for benefit among this population. The proposed intervention offers a 16-week DBT
program, alongside a psychoeducational workshop for parents, delivered within a school
setting. It also recommends mental health promotion within rural communities and schools.
In delivering an evidence-based and comprehensive intervention, self-harm may be addressed
more effectively among these vulnerable Australians, as well as contribute to the existing
literature.
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References
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Australian Institute of Health and Welfare (AIHW). (2014). Suicide and Hospitalised Selfharm in Australia. Retrieved from: https://www.aihw.gov.au/getmedia/b70c6e7340dd-41ce-9aa4-b72b2a3dd152/18303.pdf.aspx?inline=true
Bennardi, M., McMahon, E., Corcoran, P., Griffin, E., & Arensman, E. (2016). Risk of
repeated self-harm and associated factors in children, adolescents and young adults.
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BMC Psychiatry, 16, 1-12. doi: 10.1186/s12888-016-1120-2
Boyce, P., Carter, G., Penrose-Wall, J., Wilhelm, K., & Goldney, R. (2003). Summary
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Fortune, S., Sinclair, J., & Hawton, K. (2008). Adolescents’ views on preventing self-harm.
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attitudes to seeking help for mental health problems. Youth Studies Australia, 25(4),
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42-49
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Freeman, K., James, S., Klein, K., Mayo, D., & Montgomery, S. (2016). Outpatient
Dialectical Behaviour Therapy for Adolescents Engaged in Deliberate Self-Harm:
Conceptual and Methodological Considerations. Child & Adolescent Social Work
Journal, 33(2), 123-135. doi: 10.1007/s10560-015-0412-6
Guerreiro, D. F., Cruz, D., Frasquilho, D., Santos, J., Figueira, M. L., & Sampaio, D. (2013).
Association Between Deliberate Self-Harm and Coping in Adolescents: A Critical
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doi: 10.1080/13811118.2013.776439
Healey, J. (2014). Self-harm and young people. Retrieved from
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Hawton, K., Rodham, K., Evans, E., & Harriss, L. (2009). Adolescents Who Self Harm: A
Comparison of Those Who Go to Hospital and Those Who Do Not. Child &
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James, A. C., Taylor, A., Winmill, L., & Alfoadari, K. (2008). A Preliminary Community
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Demonstrating Persistent, Deliberate Self-Harm (DSH). Child & Adolescent Mental
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Kõlves, K., Milner, A., McKay, K., & De Leo, D. (2012). Suicide in Rural and Remote Areas
of Australia. Australian Institute for Suicide Research and Prevention. Retrieved
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from: https://www.griffith.edu.au/__data/assets/pdf_file/0007/471985/Suicide-inThe author has not authorised any further reproduction or communication of this material.
Rural-and-Remote-Areas-of-Australia.pdf
Low, G., Jones, D., Duggan, C., MacLeod, A., & Power, M. (2001). Dialectical behaviour
therapy as a treatment for deliberate self-harm: Case studies from a high security
psychiatric hospital population. Clinical Psychology & Psychotherapy, 8(4), 288-300.
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Madge, N., Hawton, K., McMahon, E., Corcoran, P., Leo, D., Wilde, E., & … Arensman, E.
(2011). Psychological characteristics, stressful life events and deliberate self-harm:
findings from the Child & Adolescent Self-harm in Europe (CASE) Study. European
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Ougrin, D. (2012). Commentary: Self-harm in adolescents: the best predictor of death by
suicide? – reflections on Hawton et al. (2012). Journal Of Child Psychology &
Psychiarty, 53(12), 1220-1221. doi: 10.1111/j.1469-7610.2012.02622.x
Ougrin, D., Kyriakopoulos, M., Zundel, T., Banarsee, R., Stahl, D., & Taylor, E. (2012).
Adolescents With Suicidal and Nonsuicidal Self-Harm: Clinical Characteristics and
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Response to Therapeutic Assessment. Psychological Assessment, 24(1), 11-20. doi:
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10.1037/a0025043
Rughani, J., Deane, F. P., & Wilson, C. J. (2011). Rural adolescents’ help-seeking intentions
for emotional problems: The influence of perceived benefits and stoicism. Australian
Journal Of Rural Health, 19(2), 64-69. doi: 10.1111/j.1440-1584.2011.01185.x
Scott, S., Diamond, G. S., & Levy, S. A. (2016) Attachment-Based Family Therapy for
Suicidal Adolescents: A Case Study. Australian & New Zealand Journal Of Family
Therapy, 37(2), 154-176. Doi: 10.1002/anzf.1149
Tormoen, A., Rossow, I., Larsson, B., & Mehlum, L. (2013). Nonsuicidal self-harm and
suicide attempts in adolescents: differences in kind or degree? Social Psychiatry &
Psychiatric Epidemiology, 48(9), 1447-1455. doi: 10.1007/s00127-012-0646-y